MEDICARE: QUEEN CREEK COUNSELING LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	LCSW-2854	AZ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1033441514
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	QUEEN CREEK COUNSELING LLC

Provider Business Mailing Address
First Line	:	PO BOX 1598
Second Line	:
City	:	QUEEN CREEK
State	:	AZ
Zip	:	85142-1835
Country	:	US
Telephone Number	:	480-258-2915
Fax Number	:	480-888-0231

Provider Business Practice Location Address
First Line	:	21321 E OCOTILLO RD
Second Line	:	B-105
City	:	QUEEN CREEK
State	:	AZ
Zip	:	85142-5996
Country	:	US
Telephone Number	:	480-258-2915
Fax Number	:	480-888-0231

Authorized Official
Title or Position	:	OWNER
Name	:	PAMELA CAROL DEAN
Credential	:	LCSW
Telephone Number	:	480-258-2915

Provider Enumeration Date	:	02/08/2010
Last Update Date	:	02/08/2010

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Directions to “QUEEN CREEK COUNSELING LLC ” Practice Location

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